Rosen & Barkin's 5-Minute Emergency Medicine Consult (509 page)

• Lader M. Management of panic disorder.
  Expert Rev Neurother.
  2005;5(2):259–266.
  
• Lessard MJ, Marchand A, Pelland MÈ, et al. Comparing two brief psychological interventions to usual care in panic disorder patients presenting to the emergency department with chest pain.
  Behav Cogn Psychother.
  2012;40(2):129–147.
  
• Marchesi C. Pharmacological management of panic disorder.
  Neuropsychiatr Dis Treat.
  2008;4(1):93–106.
  
• Pelland MÈ, Marchand A, Lessard MJ, et al. Efficacy of 2 interventions for panic disorder in patients presenting to the ED with chest pain.
  Am J Emerg Med.
  2011;29(9):1051–1061.
  
• Susman J, Klee B. The Role of High-Potency Benzodiazepines in the Treatment of Panic Disorder.
  Prim Care Companion J Clin Psychiatry.
  2005;7(1):5–11.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Psychosis, Medical vs. Psychiatric
  
• Withdrawal, Drug
  

CODES

• 300.01 Panic disorder without agoraphobia
  
• 300.21 Agoraphobia with panic disorder
  

BASICS

• The entrapment of the retracted foreskin proximal to the glans of the penis
  
• Leads to lymphatic congestion and venous obstruction, which may result in arterial compromise to the glans
  
• Paraphimosis is a urologic emergency.
  

• A number of conditions of the foreskin may predispose to paraphimosis, including:
  
  • Phimosis
    
  • Inflammation
    
  • Trauma
    
  • Sexually naive may be unaware of the need to reduce foreskin after intercourse
    
• Commonly iatrogenic, from failure to replace the foreskin after exam, catheterization, or cleaning
  

DIAGNOSIS

• Retracted prepuce (foreskin)
  
• Pain
  
• Swollen, edematous glans
  
• Local cellulitis
  
• Necrosis of glans in untreated cases
  

Exam of the genitalia should include a search for constricting foreign bodies or constricting bands.

• Paraphimosis is a clinical diagnosis with the clinical findings described earlier.
  
• Treatment must not be delayed pending diagnostic lab or radiographic studies.
  

If history suggests penile foreign body, radiographs may be obtained once the vascular compromise has been relieved.

• Foreign bodies constricting the penile shaft may mimic paraphimosis; these include:
  
  • Hair tourniquets
    
  • Wire, string, or other materials used for sexual enhancement or punishment
    
• Balanoposthitis
  
• Trauma (zipper injuries)
  
• Acute idiopathic penile edema
  

TREATMENT

• Patients should be transported promptly; do not attempt reduction in the field.
  
• Pre-hospital personnel can be advised to apply an ice pack to the glans with adequate protection of the skin.
  
• Pain control
  

• Ice can be applied to the glans while preparing to reduce the prepuce:
  
  • Use the thumb of a glove as an ice-filled condom to aid in direct application.
    
• The incarcerated foreskin must be released as soon as possible to prevent ischemia and necrosis of the glans.
  
• The pain associated with reduction techniques must be managed with some combination of conscious sedation, adequate analgesia, and local anesthesia.
  

• Medical therapy for paraphimosis involves reassuring the patient, reducing the preputial edema, and restoring the prepuce to its original position and condition.
  
• The following sequence of procedures should be followed:
  
  • Paraphimosis can most frequently be reduced using a penile block and compressing the glans manually while applying traction on the foreskin.
    
  • Penile block is performed by infiltrating 5 mL of 1% lidocaine
    without
    epinephrine in the angle between the inferior rami of the symphysis pubis:
    
    • Then use another 5 mL to infiltrate a wheel along the sides of the penis.
      
    • This produces a block after 5 min.
      
  • Successful reduction requires steady circumferential pressure on the distal edema with simultaneous manual reduction of the foreskin.
    
  • In children, conscious sedation is usually required.
    
  • If manual reduction is unsuccessful, then the technique of multiple punctures may facilitate reduction:
    
    • Make ∼20 holes in the swollen foreskin with a small sterile needle (26G), allowing expression of edema fluid, then resume manual reduction.
      
  • If this fails to return the foreskin to its original position, it will be necessary to incise the constricting ring of tissue with a dorsal longitudinal slit in the foreskin after sterile preparation:
    
    • If the incision made is too long, after reduction it may be necessary to suture the incision transversely with 3.0 absorbable sutures.
      
• If a delay is likely before the paraphimosis can be treated (e.g., NPO status), then applying a gauze swab soaked in 50% dextrose will reduce edema by osmosis and facilitate reduction.
  
• For patients who want to retain uncircumcised phallus steroid therapy can be attempted to reduce fibrose ring. Consult urology for close follow-up:
  
  • Triamcinolone cream 0.1% to affected area × 6 wk
    
  • If unsuccessful, circumcision may still be required.
    

• Appropriate analgesics or anesthetics as required
  
• Antibiotics generally not required unless treating associated cellulitis or balanoposthitis.
  

FOLLOW-UP

Necrosis or cellulitis of the penis

• Successful reduction with relief of symptoms
  
• Close urologic follow-up
  

• Urologic consultation is required.
  
• Subsequent circumcision to prevent recurrence is an area of clinical debate; historically, it has been common practice.
  

• Education regarding importance of replacement of the foreskin after retraction for instrumentation or cleaning
  
• Emphasis on prepuce hygiene
  

• Goal is to reduce penile edema enough to allow the foreskin to return to original position over the glans.
  
• Generally, noninvasive reduction methods (at least 2 or 3 attempts) are successful and dorsal slit incision is mostly required only in severe cases.
  

• Donohoe JM, Burnette JO, Brown JA. Paraphimosis treatment.
  eMedicine
  . Available at
  http://www.emedicine.medscape.com/article/442883
  . Updated October 7, 2009.
  
• Ghory HZ, Sharma R. Phimosis and paraphimosis.
  eMedicine
  . Available at
  http://www.emedicine.medscape.com/article/777539
  . Updated April 28, 2010.
  
• Huang CJ. Problems of the foreskin and glans penis.
  Clin Pediatr Emerg Med
  . 2009;10:56–59.
  
• Marx JA, Hockberger RS, Walls RM.
  Rosen’s Emergency Medicine: Concepts and Clinical Practice
  , 7th ed. St. Louis, MO: Mosby; 2009:2201–2202.
  
• Ramos-Fernandez MR, Medero-Colon R, Mendez-Carreno L. Critical urologic skills and procedures in the emergency department.
  Emerg Med Clin North Am.
  2013;31(1):237–260.